1932249109 NPI number — ATHLETIC AND THERAPEUTIC INSTITUTE OF JOLIET LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932249109 NPI number — ATHLETIC AND THERAPEUTIC INSTITUTE OF JOLIET LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ATHLETIC AND THERAPEUTIC INSTITUTE OF JOLIET LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1932249109
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1408 JOLIET RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROMEOVILLE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60446-4064
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-783-2001
Provider Business Mailing Address Fax Number:
630-783-0117

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
330 MADISON ST
Provider Second Line Business Practice Location Address:
LL14
Provider Business Practice Location Address City Name:
JOLIET
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60435-6565
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-553-1010
Provider Business Practice Location Address Fax Number:
815-553-1011
Provider Enumeration Date:
02/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BOGOVICH
Authorized Official First Name:
MARK
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
630-633-5557

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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